Review of pain medications used for treating bone and spine pain
Lets be clear, bone and spine pain may have many different underlying causes, and quite often, the exact known cause of pain for any one particular patient may go unknown for quite some time. Most people with chronic bone or spine pain (pain that persists for more than three months) will treat them selves with over the counter therapies until the pain becomes unbearable and they find themselves at their doctors office or in an urgent care clinic of some kind looking for relief.
There are different treatment alternatives that include diet, stretching, physical therapy, exercise, chiropractic manipulation, surgical procedures, topical medication, injectable medication and oral medication therapy. It is important to discuss with your doctor which is the best combination of treatments for you, however, my goal here is to help educate you about the different oral and topical medication treatment options available.
Please understand, this is not a shopping list to take to the doctor. This reference should help you understand the different treatment options available so that you may have an educated discussion about your options with your doctor.
Over-The-Counter Pain Medications
Topical Counter-Irritants work on minor joint pain by creating a feeling of warmth or coolness over a painful area. They vary in active ingredients such as camphor, eucalyptus or menthol. They are effective at providing short term relief in minor pain.
Topical Capsaicin is helpful at relieving pain that comes from the nerves near the surface of your skin. It works well for localized joint pain. This is hot pepper cream and will block the transmission of pain from the nerve endings. Start with a small dose and gradually increase over the course of 1-2 weeks to decrease the chance of feeling the burn. Please note there are two strengths of this cream. It is important to first start with the lower dose and increase to the stronger strength after you have used at least one tube of the smaller strength capsaicin. Be sure to wash your hands well so you do not get this cream in your eyes!
Glucosamine Sulfate is a natural substance that is found in healthy cartilage. It is believed that glucosamine, in the sulfate form, can aid in the strengthening of the cartilage matrix of joints and decrease progression of joint deterioration. Glucosamine sulfate is commonly taken with chondroitin which is another naturally occurring substance found in cartilage. Use of this combination may allow for a reduced dose of other prescription medications. You may need to take the combination for up to 3 months before you notice a strong positive effect. Sometimes the positive effects are so slow that many people do not even realize it is helping until they stop taking it and the pain begins to come back.
Acetaminophen (Tylenol) is an effective non-prescription medication for bone and spine pain and generally has very few side effects. Acetaminophen does not have any anti-inflammatory effects; rather, it blocks the perception of pain in the brain. Acetaminophen has the benefit that there is no chance of addiction, it rarely causes stomach upset and you do not develop a tolerance to the medication. The risk with acetaminophen is that it is easy to take too much of it, which may cause serious liver problems. Please read the packaging and do not take more acetaminophen than is directed on the label. Also, please be aware, many prescription medications contain acetaminophen in combination with another medication. Be sure to keep track of your daily acetaminophen dose to be sure you do not get more than 3000-4000mg daily.
Ibuprofen and naproxen are two non-prescription non-steroidal anti-inflammatory medications available. Ibuprofen and naproxen work differently than acetaminophen to relieve pain, so, a patient in significant pain may take the recommended dose of acetaminophen alternating with the recommended dose of ibuprofen and repeat this pattern as appropriate to treat the pain.
Prescription Pain Medications
Non-Steroidal Anti-Inflammatory Medications: Celicoxib, Diclofenac, Etodolac, Ibuprofen, Meloxicam , Nabumatone, Naproxen, Piroxicam
These medications work best when taken on a regular basis. The idea is that the medication builds up in the system and work to block the inflammatory process. Decreasing the inflammation will help decrease the pain. There are a number of potential risks and side effects related to the heart, stomach, and intestines. Please talk with your doctor to decide which medication would be best for your specific condition.
Nerve Pain Medications: Pregabalin, Gabapentin, Duloxetine
These interfere with specific signals in nerve pathways that involve the transmission of pain impulse recognition. These medications are usually not addictive and may be taken safely for long periods of time. That said, this category of medications is sometimes difficult for people to start. The dose of any of the three will most likely be titrated up slowly over a course of 1-4 weeks to minimize the side effects. It helps to know that the body will usually acclimate to the medication over the course of a few weeks and the side effects will diminish as the pain control increases.
Narcotic Pain Medications: Oxycodone/Acetaminophen, Hydrocodone/Acetaminophen, Oxycodone Extended-Release, Fentanyl Patch, Morphine Extended Release
Narcotic pain medications (opiates) work very well at treating bone and spine pain for short term therapy after a surgery or an acute injury of some kind. Opiates block the perception of pain in the central nervous system. They don't actually treat the cause of the pain, they just block your perception of it so you have a decreased sensation of pain. One of the big issues with opiate pain therapy is that after 2-3 weeks of treatment, the body slowly begins to build up a tolerance to the medication. This may sometimes be perceived as an increase in pain, rather than a decrease in effectiveness and the dosage may be increased. If not monitored and talked about regularly, this can lead to a self-defeating addiction to opiates with an escalating need for pain control. That said, there are some physicians who use low dose, long-acting opiates to treat chronic one and joint pain effectively for long periods of time. Please discuss all aspects of narcotic pain control with your doctor or pharmacist before beginning chronic opiate pain control.
Muscle Relaxants: Diazepam, Cyclobenzaprine, Carisoprodol, Tizanidine, Methocarbamol
Muscle relaxants may be prescribed for an acute flare up of bone or spine pain when the pain is associated with muscle spasms. This type of medication may help relax muscles, decreasing the pressure that the muscle is placing on the nerve and reduce pain. The trouble with this approach is that the muscle relaxant is not specific for the muscle spasm. All of the muscles will be relaxed and may significantly decrease your reflex response capability. In other words, don't drive and don't drink any alcohol while taking these medications. Quite often this category is prescribed for back or neck pain to help relax a muscle so someone may sleep at night. Please discuss with your doctor or pharmacist how long you should take your muscle relaxant for and to make sure you are aware of the important information associated with your specific muscle relaxant.
Tramadol is an alternative to opiate pain medications for treatment of moderate to moderately severe acute pain such as you might have post-operatively or after an acute injury. Tramadol is not a narcotic; however, it works by stimulating the same opioid receptors in the central nervous system that opiates do. It also decreases pain by increasing the levels of specific neurotransmitters, similar to how nerve pain medications work. This medication is also associated with addictive behavior. Because it works in the central nervous system, you still need to be aware of the potential of side effects such as light headedness, dizziness and drowsiness. It is important to note that someone would usually not take Tramadol and an opiate at the same time because one may block the effects of the other. Please discuss this option with your doctor as an alternative to taking short acting narcotic pain medications.
Corticosteroid Medications: Dexamethasone, Methylprednisolone, Prednisone
Corticosteroids are sometimes used for short term therapy(7-14 days) to decrease inflammation in an acute situation. There are generally only a few complications associated with short term use of corticosteroids such as upset stomach, restlessness and agitation. Long term use of corticosteroids may be associated with osteoporosis, compromised immune system, stomach ulcers and possible other complications. Please note that caution should be used when someone with diabetes is prescribed a corticosteroid because this medication increases blood sugar. Also, if steroids are used in someone with an acute infection, the infectious condition may worsen. Please make sure your doctor and pharmacist are aware of your current medical conditions and other medications before you begin a course of oral corticosteroids.
Topical Prescription Pain Medications
Diclofenac Gel (Voltaren Gel): Topical anti-inflammatory gel massaged into the affected painful area 3-4 times daily. Effective for localized joint pain. Has the benefit of bypassing the GI tract, however, it is short acting and really needs to be used 4 times daily for a reasonable effect.
Diclofenac Patch: The same medication that is in the Voltaren Gel, however, it is in a patch. Again, effective for local pain control if placed directly over the pain. The patch needs to be changed every 12 hours and the constant irritation of having a patch on the same location can cause skin irritation in some patients.
Lidocaine Patch: Provides transdermal lidocane (anesthetic) to help numb the pain. It is quite effective for some patients. The patch is only worn for 12 hours every 24 hours.
This is meant as a general over view of the oral and topical medications commonly used for treatment of bone and spine pain. Please discuss with your doctor what the best course of treatment is for your situation. If you have any questions about any of the medications listed here, I encourage you to contact your community pharmacist and engage them in a discussion.
About The Author
Dr. Steve Leuck is currently a community pharmacist in a hospital out-patient pharmacy, where he educates and motivates patients to participate in their own pharmaceutical care. He is also owner of AudibleRxTM where OBRA 90 based Medication Specific Counseling SessionsTM are available in audio format.
This medication summary is for information only and is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.
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